Version July 2025
INTRODUCTION —
Optimal local treatment of burn wounds depends on gentle cleansing and debridement to minimize the incidence of complicating infection as well as further injury to the wound bed. Routine burn wound dressing changes typically incorporate the application of topical antimicrobial agents; however, there is no consensus as to which agent or dressing is optimal for burn wound coverage, to prevent or control infection, or to enhance wound healing [1,2].
The selection and application of burn wound dressings and topical agents depend upon the nature and extent of the burn wound, the particular wound quality or state (eg, presence and degree of contamination, infection, exudate), and the patient's allergy history. The dressings and topical therapies that are used at a given facility depend upon regional and individual preferences and experience, availability, and costs.
The most frequently used burn wound dressings and topical agents for use in adults and children are reviewed. The classification and management of burns by depth of burn and the specialized management of burns at specific anatomic sites are reviewed separately.
●(See "Assessment and classification of burn injury".)
●(See "Treatment of minor thermal burns".)
●(See "Treatment of epidermal/superficial partial-thickness burn injury requiring hospital admission".)
●(See "Treatment of deep burn injury".)
●(See "Principles of burn reconstruction: Extremities and regional nodal basins".)
LOCAL BURN WOUND CARE
Goals — Local burn wound care (table 1 and table 2) aims to protect the wound surface and maintain an appropriately moist environment, one that is neither too dry nor too wet to prevent desiccation or maceration, respectively, in an effort to promote burn wound healing, limit burn wound progression while minimizing discomfort for the patient, and protecting surrounding skin and tissues [3]. It is important to note that topical antimicrobials are used in conjunction with appropriate basic wound care. (See "Principles of acute wound management".)
Burn wound surfaces are prone to rapid bacterial colonization with the potential for invasive infection. Measures to reduce the likelihood of infection include good infection control practices, topical antimicrobial therapy, and burn wound debridement/excision when needed [4]. Closed dressing management is often advocated to minimize cross-contamination by pathogens (eg, methicillin-resistant Staphylococcus aureus) that can cause burn wound infection, delayed wound healing, and loss of skin grafts [5]. Wounds that become infected may require systemic antimicrobial therapy in addition to the chosen regimen for local wound care. Available evidence does not support the role of systemic antibiotic prophylaxis in the management of superficial, non-infected burns [6]. (See "Burn wound infection and sepsis".)
Prior to the application of topical agents and dressings, the acute wound site should be carefully inspected and gently cleansed.
Dressings — A variety of antimicrobial agents (see 'Antimicrobial agents' below) can be applied to the burn wound surface, which is then covered with one of several dressing materials (eg, gauze, nonadherent films) (table 1 and table 2).
Our approach to local burn wound care is based on burn wound depth (table 3). However, early after injury, it may be difficult to accurately determine the depth of burn wounds, particularly as burn wounds are often of mixed depths. More than one local wound care regimen may be necessary in addition to protecting surrounding skin and structures. Our general approach is summarized below and discussed in more detail separately. (See 'Efficacy and use of topical therapy' below and "Treatment of epidermal/superficial partial-thickness burn injury requiring hospital admission" and "Treatment of deep burn injury".)
●Gauze alone should be avoided unless there are no other options (ie, disaster settings or when topical antimicrobials are not available). Dry gauze promotes scab formation, which will generally separate spontaneously as re-epithelialization occurs. In addition, pain can be significant when the gauze is removed.
●Nonadherent films or fine mesh gauze (in combination with topical antimicrobials) are common dressings used to cover the burn wound.
●Foams, alginates, hydrocolloids, and hydrogels can also be used depending on the specific qualities of the dressing (eg, silver-containing) and the specific needs of the burn wound. These can be used to either cover a burn wound treated with a topical agent or applied directly to the wound bed. Partial-thickness burns may often have moderate-to-high amounts of exudate and, as such, may often be appropriately managed with foams and alginates. By comparison, for a graft donor site that has minimal-to-moderate exudate, the use of polyurethane, hydrocolloids, or hydrogels may serve well.
Coverage of clean, uninfected burn wounds can also be accomplished using biologic dressings, biosynthetic dressings, and skin substitutes. These are generally applied once and adhere to the wound, separating spontaneously as healing progresses [7]. (See 'Temporary burn wound coverage' below.)
Dressing changes should be frequent enough to control exudate but not so frequent that they interfere with wound re-epithelialization. The frequency of dressing changes ranges from twice daily to weekly, depending upon the amount of exudate and choice of dressing material. More frequent dressing changes are performed if there is a large amount of exudate, weeping, or infection [8].
Topical antimicrobials should be gently removed with dressing changes. Excessive scrubbing and sharp debridement are not necessary and can be very painful for the patient and hinder healing. Management of pain in association with burn wound care is discussed separately. (See "Paradigm-based treatment approaches for management of burn pain", section on 'Procedural pain' and "Management of burn wound pain and itching".)
ANTIMICROBIAL AGENTS —
Commonly used topical agents include combination antimicrobial ointments, silver sulfadiazine, bismuth-impregnated petroleum gauze, mafenide, and chlorhexidine [1,2,9,10]. Other agents such as honey, povidone-iodine, and Dakin's solution are less commonly used. Combinations of antimicrobials with topical antifungal agents have also demonstrated some efficacy for the local treatment of burns [11].
Some of the agents have variable degrees of local or systemic adverse effects, which may impede wound healing (table 1) [1,4,12]. However, there is no official standard for testing the efficacy and cytotoxicity of topical antimicrobial agents [13].
Commonly used agents — Commonly used topical agents for partial-thickness burns include antimicrobial ointments, silver-containing agents, bismuth-impregnated petroleum gauze, chlorhexidine, and mafenide [9,10].
Antimicrobial ointments — Topical antimicrobial ointments (as single agents or as combination agents) are commonly used for superficial burn wounds. Compared with silver sulfadiazine, the advantages of these are ease of application and removal for wound cleansing. In addition, these can be used in areas of sensitivity, such as on the face, ears, and perineum (table 1). For most centers queried in the authors' communications with several well-known burn centers in the United States and Europe, antimicrobial ointments remain the most commonly applied topical agent for the treatment of small to moderate partial-thickness burn wounds where primary epithelization is expected.
For uncomplicated burn wounds, many clinicians apply Polysporin ointment covered by a nonadherent dressing. Polysporin is a combination of bacitracin zinc and polymyxin B sulfate. It can be used to treat superficial and some partial-thickness burns, particularly those that involve the face and perineum [10]. However, it is important to note that its efficacy in the treatment of infected wounds has not been clearly established. In the setting of methicillin-resistant Staphylococcus aureus (MRSA), mupirocin ointment/cream is effective [14]. Areas near the eyes are generally managed with ophthalmic derivatives, such as neomycin or erythromycin ophthalmic ointment. Otherwise, the use of neomycin is generally limited to smaller burn areas. It is frequently mixed (diluted) with bacitracin and polymyxin to reduce absorption [10].
Bacitracin, neomycin, and polymyxin B have negligible systemic absorption after topical administration except when applied to large areas or for long periods. Polymyxin B has little absorption, even when applied to open wounds. However, it should be noted that systemic absorption has been reported when bacitracin, neomycin, or gentamicin has been applied to damaged epithelium [15]. If absorbed systemically, bacitracin, neomycin, or polymyxin B can cause nephrotoxicity and neurotoxicity. Caution should be used in patients with impaired kidney function and those taking medications with nephrotoxic or neurotoxic adverse effects. An alternative is to limit the duration of use and/or to alternate with topical agents that are not absorbed.
Silver-containing agents — Silver-containing agents slowly release ionic silver into the wound (table 1). Activated silver has broad-spectrum antimicrobial activity and may also have an anti-inflammatory benefit [16]. There are several silver-containing preparations and dressings, including silver sulfadiazine, nanocrystalline silver (eg, Acticoat, Aquacel Ag), and silver nitrate, each of which has its management requirements. Silver formulations that contain silver nitrate and silver sulfadiazine require more frequent dressing changes. Silver nitrate can temporarily stain the skin a dark brown or black in color. This staining is self-limited and fades after discontinuing treatment [17].
Silver sulfadiazine — Silver sulfadiazine cream (SSD 1%) applied and covered with fine mesh gauze is the most commonly used burn wound dressing [1]. SSD is widely available and relatively inexpensive and continues to be used in many burn centers as the standard of care for the treatment of burn wounds, with a long history and experience with its use.
SSD has antimicrobial activity, as demonstrated by decreased colonization of burn wounds. However, there are no well-designed trials to confirm improved wound healing or a reduced rate of bacterial wound infection [1,18]. For wounds covering more than 50 to 60 percent of the total body surface area, SSD does not consistently prevent or suppress bacterial growth, particularly of gram-negative bacteria [19]. In addition, there are potential adverse effects. As an example, SSD will form a pseudoeschar that is loose at the edges, which can promote bacterial proliferation. The pseudoeschar requires removal or debridement to improve the ability to monitor the wound state and facilitate re-epithelialization. SSD also impedes re-epithelialization; as a result, SSD should be stopped when there is evidence of re-epithelialization [1].
SSD is a thick white cream that is applied once or twice daily and can be soothing. SSD and related agents should not be used during pregnancy, while breastfeeding, or in infants younger than two months old [20]. SSD is also oculotoxic and should not be used near the eyes [21].
Cerium nitrate, one of the lanthanide rare earth elements, can be added to SSD for burns not undergoing immediate excision and closure [19,22-24]. While not approved for use in the United States, it is commonly available in Europe and other countries around the world.
Cerium nitrate is applied topically either alone or in addition to other silver dressings, converting the eschar into reportedly a pliable and protective crust [25]. Reports in adult and pediatric burn populations have been conflicting regarding the clinical value of cerium as measured by mortality, length of hospital stay, and bacterial colonization of the wounds. In two trials in the Cochrane review, there were fewer deaths in groups treated with cerium nitrate plus SSD compared with SSD alone (relative risk [RR] 0.22, 95% CI 0.05-0.99 [22,26]). Other studies that did not address these clinical outcomes have found that SSD-cerium was not more effective than SSD alone in reducing burn wound colonization [27,28].
Nanocrystalline silver — Nanocrystalline silver dressings are composed of a urethane film embedded with elemental silver that provides sustained release of silver into the wound. Compared with older silver formulations, it has stronger antimicrobial activity and longer-lasting properties that reduce dressing change frequency to weekly, depending upon the amount of exudate [29]. Some nanocrystalline silver dressings (eg, Acticoat) require frequent moistening with water to maintain activation.
In a systematic review, compared with SSD, nanocrystalline silver had a lower incidence of infection (9.5 versus 27.8 percent, odds ratio 0.14, 95% CI 0.06-0.35) [30]. Nanocrystalline silver was also associated with less pain during dressing changes and lower cost.
In a trial comparing Acticoat with Allevyn (an occlusive moist-healing environment material), skin graft donor sites dressed with Allevyn re-epithelialized at a faster rate [31]. The opposite effect was found in another trial in which wounds treated with Acticoat re-epithelialized faster with better comfort compared with Allevyn [32]. Both studies agreed that there was no difference in bacterial colonization of the donor site.
Bismuth-impregnated petroleum gauze — Bismuth-impregnated petroleum-based gauze is comparable to other topical antimicrobial agents [33,34]. Bismuth-impregnated gauze is an often-preferred dressing for skin graft donor sites and for covering fresh skin grafts, and it is also an excellent option for very small superficial partial-thickness burns where clinical judgment indicates antimicrobial activity is necessary.
Bismuth-impregnated gauze is applied as a single layer over the burn and then covered with a bulky dressing [20]. The dressing will separate from the wound when it has re-epithelialized. Bismuth-impregnated petroleum gauze is particularly useful in children as it is applied only once, decreasing the pain that typically accompanies wound dressing changes [35].
Mafenide acetate — Mafenide acetate (table 1), a potent carbonic anhydrase inhibitor, is an alternative to SSD and may be useful for treating patients with dense bacterial proliferation of the burn wound [36-40]. Many centers alternate silver sulfadiazine cream with mefenide acetate to broaden coverage while minimizing potential adverse reactions.
Mefenide acetate has been shown to provide coverage for multidrug-resistant organisms such as Pseudomonas aeruginosa, extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, Acinetobacter baumannii complex, and MRSA, but has limited efficacy against yeast [41]. It is often advocated for use in full-thickness burn wounds where its eschar penetration capability may prove advantageous, particularly over burned areas that invest delicate cartilage such as the ear or nasal ala.
In a study of 669 burn patients treated with 5% mafenide solution as either the initial topical antimicrobial agent (276 patients) or for chronic treatment, effective activity was achieved, and only 1 percent experienced pain severe enough to discontinue therapy [40]. There was a very low incidence of rash and pruritus and no cases of metabolic acidosis.
Mafenide acetate can also be applied as a cream once or twice daily at a thickness of approximately 1/16 of an inch [42]. Treatment is typically continued until the burn site is healed or ready for skin grafting.
Adverse reactions associated with the use of mafenide include metabolic acidosis, allergic reactions (eg, rash, pruritus, hives, erythema, eosinophilia), and respiratory complications (eg, tachypnea, decrease in arterial pCO2) [43,44].
Chlorhexidine — Chlorhexidine gluconate (table 1), a long-lasting antimicrobial skin cleanser, is often used with a gauze dressing for burn wound coverage in superficial partial-thickness burns. Chlorhexidine dressings do not interfere with wound re-epithelialization, in contrast to silver sulfadiazine [1]. A combination preparation of silver sulfadiazine and chlorhexidine gluconate has also been used [45,46].
Others
Honey — Honey-derived wound care dressings heal limited superficial partial-thickness wounds as well as, or better than, several other conventional treatment options such as polyurethane film, paraffin gauze, Soframycin-impregnated gauze, sterile linen, or leaving the burns exposed [47,48]. However, the safety, efficacy, and use of honey-based dressings for the treatment of more severe, extensive, or complex thermal injury has not been established.
There are few high-quality studies, but evidence from low-quality studies and anecdotal reports in burn patients suggest that honey-derived wound care dressings are generally well tolerated and may show adjunctive efficacy in the treatment of a variety of wound types [1]. In a systematic review comparing honey dressings with silver sulfadiazine, honey improved healing time (mean difference [MD] -5.76 days, 95% CI -8.14 to -3.39) and the proportion of infected wounds rendered sterile (RR 2.59, 95% CI 1.58-2.88) [48]. An earlier systematic review similarly supported the use of honey in burn wound care while noting the generally low methodologic quality of the available randomized trials [49].
Povidone-iodine — Povidone-iodine ointment, including a liposomal preparation, effectively combines antimicrobial therapy with a desired moist wound environment. Despite a broad spectrum of antimicrobial activity [50,51], povidone-iodine-containing products in burn care are controversial because of cytotoxicity and delay in wound re-epithelialization [12,50,52]. Another drawback to povidone-iodine ointment compared with other topical agents is that it must be applied four times a day for maximal antimicrobial effect.
Dakin's solution — Dakin's solution (0.025% sodium hypochlorite) is widely used in a variety of difficult wound types and has been advocated by some for the management of burn wounds. It has broad-spectrum antimicrobial activity with efficacy in the clinical setting of MRSA, Vancomycin-resistant Enterococcus (VRE), and other antibiotic-resistant bacteria [53].
Proponents of Dakin's solution note its broad spectrum of action, minimal cost, and cytoprotective benefits (little impact on fibroblast function). While there are few well-defined papers to strongly advocate its use in burns, it may hold promise, particularly in settings where funding and availability of other standard dressing regimens are lacking. Pain control issues have been noted [53].
DEBRIDING AGENTS —
Enzymatic debriding agents and proteolytics have been successfully used for the early management of deeper and indeterminate depth surgical burn wounds and eschar for many years [54-60]. The aim of using these agents is expedited debridement while affording a measure of specificity and dermal preservation. Clean and more superficial injuries can benefit from gentle debriding agents such as hydrogels and hydrocolloid dressings that facilitate autolytic debridement, whereby the body aids in removing nonvital tissue [61].
Products have included collagenase derivatives, a variety of fruit enzyme derivatives such as papain/urea derivatives, and bromelain derivatives. Later-generation products have demonstrated greater specificity to eschar. One bromelain derivative, anacaulase (NexoBrid), has been granted approval for use in the United States [54], European Union [62], and other international markets for the treatment of small- to moderate-sized intermediate and deep dermal thickness burn wounds. While this agent was initially approved by the US Food and Drug Administration for eschar removal only in adults with deep partial-thickness or full-thickness thermal burns, it was later approved for these same indications based on a global phase 3 clinical trial. Precautions include attention to potential bleeding risk, allergies, and adequate analgesia.
TEMPORARY BURN WOUND COVERAGE
Biologic grafts — Biologic graft materials that can be used for temporary coverage of burn wounds include allografts, xenografts, and others (eg, human amnion). These help promote healing or can serve as a bridge to definitive burn wound coverage. Skin autografts and the use of dermal generation templates for permanent coverage of burn wounds are discussed separately. (See "Overview of surgical procedures used in the management of burn injuries" and "Skin autografting".)
Biologic grafts can be used on clean burn wounds, and they protect the wound from desiccation while promoting re-epithelialization. The graft separates from the wound once it has re-epithelialized. Biologic grafts are especially useful in children as they are applied only once, decreasing the pain that typically accompanies wound dressing changes.
●Allografts – Transient physiologic coverage can be achieved by allogeneic skin grafts (eg, from a nongenetically identical donor from the same species, also called homograft). Allografts are distributed as either fresh or cryopreserved after glycerol preservation from cadavers. The application of an allograft over superficial partial-thickness wounds can minimize pain and facilitate re-epithelialization. Allogeneic skin is generally used only in burn centers.
●Xenografts – Xenografts (ie, from an unrelated species [heterografts] are generally readily available but may not be as effective as allografts. Skin xenografts are used as temporary skin coverage, especially for large burn wounds. The skin from various animals has been used. However, market challenges have resulted in the loss of porcine xenograft for much of the United States. Full-thickness cod (fish) skin marketed as "Kerecis" and classified as a medical device has been promoted for use in burn wounds with several favorable clinical reports in publication. At present, the somewhat higher cost and the lack of a definitive, large, randomized control study may preclude many of its potential uses and applications [63]. It is interesting to note that Tilapia skin has been used in Brazil for many years, primarily as a partial thickness burn wound dressing [64].
●Human amnion – Human amniotic membrane has been successfully used as a biologic dressing for partial-thickness wounds [65,66]. However, concerns regarding pathogenic transmission have limited its use. In a retrospective review of 31 studies, amniotic membrane promoted re-epithelialization of the burn wound; had antimicrobial properties; and reduced pain, fluid loss, and scar formation. An allograft consisting of sterilized, dehydrated human amnion/chorion membrane (dHACM) has also been used for burn patients [67]. dHACM contains growth factors that promote wound healing, including platelet-derived growth factors A and B, basic fibroblastic growth factor, and transforming growth factor beta 1, and it is stable at ambient temperatures for five years [68,69].
AmnioBurn is a dehydrated layered matrix consisting of human amnion and chorion membranes and is advocated for use in partial-thickness and deeper burns. After optimizing the wound bed, the matrix is rehydrated, placed onto the wound site, and covered with sterile dressings. Some health care providers will overlay the product with a topical antimicrobial or silver dressing. Reapplication may be required. Numerous reports comment on its ability to decrease pain at the wound site. However, there remains a lack of high-level studies regarding this product and its use for the treatment of burn wound injuries.
●MatriDerm – MatriDerm is a single-layer dermal substitute composed of a bovine collagen and elastin hydrolysate. It is somewhat unique to several other dermal replacement matrices in that it allows for single-stage split-thickness skin grafting. It has been used in Europe for several years and introduced in the United States in 2021 [70]. Despite several small and favorable case studies, there remains a lack of high-level studies regarding this product and its use for the treatment of burn wound injuries.
Semibiologic skin substitutes — Semibiologic skin substitutes are temporary biosynthetic dressings that are meant to reduce the number of dressing changes and facilitate healing [66]. The semipermeable nature of these dressings allows wound exudate to be absorbed by the external bulky dressing. Skin substitutes used in the local care of burns are briefly reviewed. (See "Skin substitutes".)
A variety of other formulations are available (eg, Transcyte [neonatal fibroblast incorporated into Biobrane], Suprathel [resorbable caprolactone-based materials], Omiderm [hydrophilized polyurethane membrane]). The type of skin substitute chosen depends upon the appearance of the wound, desired outcome, clinician experience, availability, cost, and cultural preferences, as some are porcine-derived [71]. In a systematic review comparing their effectiveness with silver sulfadiazine or other dressings, overall, semibiologic dressings reduced time to healing, pain medication requirements, and length of hospital stay and improved pain relief during dressing changes [1]. (See 'Efficacy and use of topical therapy' below.)
●Biobrane – Biobrane is a bilaminate membrane that contains a thin semipermeable silicone membrane bonded to a layer of nylon fabric mesh and coated with a monomolecular layer of type 1 porcine collagen [72]. The porcine collagen provides a hydrophilic coating for fibrin growth that promotes wound adherence. Biobrane has no inherent antimicrobial activity, but the membrane is porous, allowing absorption of topical antimicrobial agents and drainage of exudate. Biobrane is versatile and has additional properties of flexibility, elasticity, and transparency for wound observation. While previously not available in the US, the authors’ communications with the manufacturer suggest it will become available in the US. (See "Skin substitutes".)
•Uses – Biobrane is used to cover donor sites and aid in covering large surface area burns, including those to the hands, feet, and joints [72-82]. Biobrane is sometimes used on full-thickness excisions as a temporary covering to protect the excised wound site in a staged fashion prior to subsequent stage skin grafting. (See "Treatment of deep burn injury" and "Overview of the management of the severely burned patient".)
•Application – Biobrane is applied by gently stretching it over the burn surface to avoid wrinkles and securing it to unburned skin with adhesive strips [73]. Biobrane is covered with dry gauze, and the dressings are secured with an elastic bandage. The external dressing is changed every 24 hours, and any accumulated fluid under the Biobrane is aspirated. Biobrane can be left in place for up to 14 days, then removed in a warm bath or trimmed. Healed wounds are treated with topical agents or creams. If there is evidence of wound infection, the Biobrane is removed, and the burn is treated with topical antimicrobials. (See 'Antimicrobial agents' above.)
AWBAT, a direct derivative of Biobrane, is a porous silicone-nylon membrane coated with porcine type 1 collagen [76]. The collagen is not cross-linked to the silicone membrane, which should allow fibrin in the wound to achieve clotting and improve acute adherence, and the porosity is increased, which should reduce the fluid accumulation and the fluid pressure on the wound. Small trials have confirmed its benefit. Whether its anticipated benefits relative to Biobrane will be realized remains to be seen [77,83,84].
●Suprathel – Suprathel is applied to the wound after debridement and covered with a layer of fatty gauze. A secondary dressing with cotton gauze is applied. Suprathel and the fatty gauze remain on the wound surface until healing is complete and will separate from the re-epithelialized skin surface [74,75]. Systematic reviews of Suprathel have noted desirable properties, including no need to remove the dressing until healing, biodegradable, elastic, and reduced pain, especially in children [85,86]. While safe, effective, and generally easy to use, cost and a lack of economic assessment remain a major limitation for establishing recommendations for use.
●PermeaDerm – PermeaDerm is a biosynthetic dual-layer skin substitute that has properties that are similar to Biobrane. It is promoted for use in the treatment of partial-thickness wounds and donor sites. The outer layer is a transparent, flexible, elastic silicone nylon layer, the latter of which is coated with aloe vera to act as an epidermal analog, while the inner layer consists of a porous porcine gelatin collagen matrix. There remains a lack of high-level studies regarding this product and its use for the treatment of burn wound injuries.
●NovoSorb/PolyNovo – NovoSorb/PolyNovo is a bilayer polyurethane foam that consists of a biodegrading foam, a bonding layer, and a perforated sealing membrane. This matrix dressing acts as a scaffold for fibrovascular proliferation and is intended to improve the quality of the wound bed of deeper burns and excised wound beds for subsequent skin grafting in a manner somewhat similar to Integra. There remains a lack of high-level studies regarding this product and its use for the treatment of burn wound injuries.
●Hyalomatrix – Hyalomatrix is a synthetic nonwoven pad of a benzyl ester of hyaluronic acid. It acts as a biodegradable scaffold for cellular invasion and capillary growth and reportedly has free radical scavenging and antioxidant properties. There remains a lack of high-level studies regarding this product and its use for the treatment of burn wound injuries.
●Primatrix – Primatrix, a type II collagen dermal scaffold derived from fetal bovine dermis, is approved for full-thickness excisional wound beds and has shown some promise as an option for the treatment of deeper partial thickness burn wounds [87].
●StrataGraft – StrataGraft is a bioengineered allogeneic cellularized construct consisting of a stratified epidermal layer of normal human dermal fibroblasts on a gel collagen matrix. StrataGraft demonstrated clinical benefit in a study of 52 adult patients treated for 3 to <50 percent total body surface area deep partial-thickness thermal burns [88].
EFFICACY AND USE OF TOPICAL THERAPY —
Aggressive wound care that includes topical agents with antimicrobial activity has been associated with a reduced incidence of invasive wound infections [89,90], but the efficacy of topical therapy has not been definitively proven [1,8]. In addition, there is no consensus on which agent or dressing is optimal for managing burn wounds to prevent or control infection or enhance wound healing. The various agents are described above. (See 'Antimicrobial agents' above.)
Many randomized trials have compared the various topical agents for the treatment of burn wounds, but most are methodologically poor [1,2,10]. A meta-analysis of randomized trials concerning the topical treatment of facial burns failed to identify any specific treatment that significantly made a difference with respect to outcomes that included wound infection, scar quality, pain, and patient satisfaction [91]. A large systematic review included 56 trials with over 5800 mostly adult patients with partial-thickness burns involving less than 40 percent total body surface area (TBSA) [1]. Most studies compared a given topical agent or dressing with silver sulfadiazine (SSD). Other comparisons included alternative silver-based agents or dressings, iodine-based agents, chlorhexidine, polyhexanide, sodium hypochlorite, merbromin, ethacridine lactate, cerium nitrate, honey, aloe vera, and Arnebia euchroma. It is important to note that most comparisons did not report data on infection, which is an important clinical outcome.
The main results of this review for the treatment of superficial burns, and those of other reviews, are summarized:
●Silver versus non-silver agents – Several systematic reviews have compared various silver preparations with non-silver-containing dressings [1,18,31,92,93]. These have largely concluded that the evidence is not sufficient to establish whether silver-containing agents or dressings promote wound healing or prevent wound infection. One of these reviews suggested that there may be a detrimental effect from some silver-containing dressings [93].
In the Cochrane review, burns treated with nanocrystalline silver dressings had a shorter mean time to healing compared with Vaseline gauze (mean difference [MD] -3.49 days, 95% CI -4.46 to -2.52). There was some evidence that burns treated with honey were more likely to heal over time compared with topical antimicrobials. (See 'Honey' above.)
●Silver formulation comparison – There was no difference in the chance of healing over time comparing SSD with other silver-based agents, although other silver-based agents may have increased the number of healing events over 21- or 28-day follow-up and may slightly reduce mean time to healing [1].
In a meta-analysis of five clinical trials comparing nanocrystalline silver dressings with older silver formulation dressings (silver sulfadiazine and silver nitrate), the nanocrystalline silver group had a significantly lower rate of infections (9.5 versus 27.8 percent), decreased pain, no clear effect on hospital length of stay, and a higher cost per patient [30]. Other silver formulations (eg, Mepilex Ag) have not demonstrated differences in wound healing but have reduced the number of dressings and lower cost compared with SSD [94].
●Non-silver agent comparisons – In the Cochrane review, there were no clear differences for comparisons between most of the agents [1]. Compared with chlorhexidine, wounds treated with povidone-iodine had a reduced mean time to healing (MD -2.21 days, 95% CI 0.34-4.08).
Whether the use of specialized dressings (eg, biologic dressings/skin substitutes) improves superficial burn wound outcomes is also uncertain. A systematic review that included 30 randomized trials (most with methodologic shortcomings) did not identify an optimal dressing type [2]. A separate review of 20 trials noted that skin substitutes were at least as effective as topical agents and wound dressings or allografts for the management of partial-thickness burns [95]. For younger patients, biologic substitutes may provide optimal coverage for superficial burns. In a review of 51 observational studies and randomized trials performed in children, biologic dressings (eg, Biobrane, DuoDerm, amnion membrane) showed better results for eschar formation, length of hospital stay, healing time, and pain scores when compared with SSD [45]. (See 'Temporary burn wound coverage' above.)
Our approach — Our approach to local burn wounds is summarized and discussed in more depth in the linked topics.
Superficial burn wounds — Superficial burn wounds (superficial [epidermal], superficial partial thickness) are ideally protected by applying dressings that not only promote healing and re-epithelialization but aid in minimizing pain and further trauma. Superficial burns generally do not require antimicrobial therapy; however, for more extensive surface area burn distributions, topical antimicrobials may be used to aid in the prevention of bacterial colonization while maintaining a moist wound healing environment. It is important to note that upon early presentation after suffering burn injury, superficial partial-thickness burns may not always be easily or definitively distinguished from deeper or mixed injury patterns. As such, topical antimicrobial agents are often advocated. We generally begin with a combination antimicrobial ointment or creme (eg, Polysporin) covered with a nonadherent dressing (eg, Xeroform, Adaptic, Mepitel). With respect to burns suffered in close proximity to the eyes, we advocate the use of ophthalmic ointments without steroids. (See "Treatment of epidermal/superficial partial-thickness burn injury requiring hospital admission", section on 'Our approach'.)
Deep burn wounds — Deep burn wounds (deep partial thickness, full thickness, and deeper) require burn wound excision and graft/flap coverage. The deep burn wound site may often constitute a mixed pattern of injury with differing permeability and compromised barrier function. The role of topical agents at these wound sites is to delay the onset of an invasive infection prior to early surgical excision of nonvital tissue. The challenge is that many of these products hamper the ability of the burn team to evaluate the quality, extent, and depth of injury. As such, prior to definitive care and burn wound excision, a preliminary gauze dressing is often first applied. Excising full-thickness eschar removes the biologic and bacterial burden, decreasing morbidity and mortality while facilitating the efficacy of wound dressings, biologic grafts, semibiologic skin substitutes, and definitive coverage. Following eschar debridement and/or excision, if grafting will not take place immediately, for interim wound management, fine mesh gauze in combination with topical antimicrobials, typically silver-containing agents or dressings (eg, Silvadene, Sulfamylon, Acticoat), is used to provide a moist and minimally adherent provisional dressing until definitive debridement or surgical excision can be performed. Provisional coverage with allograft, biologic grafts, and semibiologic skin substitutes is applicable when the wound bed is optimized. Dressings are also used after surgery to cover and protect skin grafts and skin graft donor sites. (See "Treatment of deep burn injury" and "Overview of surgical procedures used in the management of burn injuries".)
Colonized/contaminated/infected burn wounds — When contamination with methicillin-resistant Staphylococcus aureus (MRSA) is suspected/confirmed, directed topical antimicrobial treatment (eg, mupirocin ointment/cream) should be added as a treatment [96]. Other treatments (eg, mafenide) may be more appropriate for heavily colonized or infected burn wounds (in addition to systemic antimicrobial therapy, as indicated). (See 'Antimicrobial ointments' above and "Burn wound infection and sepsis".)
Dressings are also used after surgery to cover and protect skin grafts and skin graft donor sites. (See "Skin autografting", section on 'Recipient site dressings and care' and "Skin autografting", section on 'Donor site dressings and care'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)
SUMMARY AND RECOMMENDATIONS
●Goals – Local burn wound care (table 1 and table 2) aims to protect the wound surface, maintain a moist environment, promote burn wound healing, and limit burn wound progression while minimizing discomfort for the patient. (See 'Goals' above.)
●Topical antimicrobial agents – A variety of antimicrobial agents (table 1) can be applied to the burn wound surface, which is then covered using one of several dressing materials. Commonly used topical antimicrobial agents include antimicrobial ointments (alone or in combination), silver sulfadiazine, bismuth-impregnated petroleum gauze, mafenide, and chlorhexidine. When contamination with methicillin-resistant Staphylococcus aureus (MRSA) is suspected/confirmed, directed topical antimicrobial treatment (eg, mupirocin ointment/cream) should be added. Other treatments (eg, mafenide) may be more appropriate for heavily colonized or infected burn wounds (in addition to systemic antimicrobial therapy, as indicated). Silver sulfadiazine, alone or with cerium, and povidone-iodine are contraindicated in burn patients during pregnancy, while breastfeeding, and in newborns. (See 'Antimicrobial agents' above.)
●Dressings – Nonadherent films or fine mesh gauze (in combination with topical antimicrobials) are common dressings used to cover the burn wound, but other materials (eg, films, foams, alginates, hydrocolloids, and hydrogels (table 2) can also be used depending on the qualities of the dressing and the specific needs of the burn wound. The frequency of dressing changes ranges from twice daily to weekly, depending upon the choice of dressing. Dressing changes should be frequent enough to control exudate but not so frequent that they interfere with wound re-epithelialization. (See 'Dressings' above.)
●Temporary burn wound coverage – Biologic graft materials and semibiologic skin substitutes can be used for temporary coverage of burn wounds to help promote healing or serve as a bridge to definitive burn wound coverage. Biologic grafts are applied only once; after the wound has re-epithelialized, the graft separates from the wound. Biologic grafts are especially useful in children. (See 'Temporary burn wound coverage' above.)
●Efficacy and use of topical therapy – Aggressive wound care that includes topical agents with antimicrobial activity has been associated with a reduced incidence of invasive wound infections, but the efficacy of topical therapy has not been definitively proven. In the absence of high-quality data and no consensus, the choice can be made based on cost, availability, frequency of dressing changes, and provider familiarity. We use the following approaches to manage superficial and deep burn wounds. (See 'Efficacy and use of topical therapy' above.)
•Superficial burn wounds – Superficial burn wounds (superficial [epidermal], superficial partial thickness) are covered with dressing materials that aid with skin healing and re-epithelialization. In general, superficial burns do not require antimicrobial therapy, but for extensive superficial burns, topical antimicrobials may be used to prevent colonization while maintaining a moist wound healing environment. Furthermore, because superficial partial-thickness burns may not always be easily distinguished from deeper injuries, topical antimicrobial agents are often used. We generally start with a combination antibiotic ointment or creme (eg, Polysporin) covered with a nonadherent dressing (eg, Xeroform, Adaptic, Mepitel). When in close proximity to the eyes, we use an ophthalmic ointment without steroids. (See "Treatment of epidermal/superficial partial-thickness burn injury requiring hospital admission", section on 'Our approach'.)
•Deep burn wounds – Deep burn wounds (deep partial thickness, full thickness, deeper burns) ultimately require burn wound excision and graft/flap coverage. Prior to definitive care and burn wound excision, a preliminary gauze dressing is often first applied. Following eschar debridement and/or excision, if grafting will not take place immediately, for interim wound management, fine mesh gauze in combination with topical antimicrobials, typically silver-containing agents or dressings (eg, Silvadene, Sulfamylon, Acticoat), is often used to provide a moist and minimally adherent provisional dressing. (See "Treatment of deep burn injury" and "Overview of surgical procedures used in the management of burn injuries" and "Overview of the management of the severely burned patient".)
